rectal instruments


By • Дек 26th, 2010 • Category: Anus

Anaerobic anorectal abscesses are uncommon, and may develop from an acute anorectal abscess which has not been operated on it time. Three forms of anaerobic abscess are distinguished: (1) suppurative; (2) progres­sive gangrenous; and (3) abscess with anaerobic lym­phangitis.

In suppurative anaerobic abscess no tissue crepitation is elicited on palpation and the pathologic process does not tend to spread. Operations consist in laying the abs­cess wide open (Fig. 68,1) and making a wide dissection of the necrotic tissues (Fig. 68,2 and 3) including a mar­gin of healthy skin. The issuing pus has an offensive sweetish smell. The cavity of a deep abscess is washed with a 4 per cent hydrogen peroxide (Fig. 68,2), rubber tubes are inserted as far as the bottom of the wounds (suppurative abscesses are usually bilateral), and the abscess cavity is packed with gauze impregnated with 4 per cent hydrogen peroxide. A large cotton-gauze dressing is then applied, with the ends of the rubber tu­bes protruding from it (Fig. 68,4). Every 4—5 hours 8 to 10 ml of 4 per cent hydrogen peroxide is injected into these tubes by means of a syringe. Antibiotics (Auromy-cin and Rondomycin) and cardiac preparations are admi­nistered if required.

No sphincterotomy is performed in anaerobic anorec­tal abscesses.

In progressive gangrenous anorectal abscess, the ope­rative procedure is begun in the same way as in suppu-rative abscess. After the necrotic tissues of the ischiorec-tal and pelvirectal fossae have been widely opened, that portion of dead fatty tissues which contains air bubbles is excised taking special care to spare the rectal wail, and 4 or 5 radial incisions are made outwards and tor-ward the ischiorectal fossa and carried through the crepi­tating tissue 2-3 cm deep as far as the boundaries of normal tissues, excercising care to avoid injury to the internal pudendal artery (Fig. 69).

The wound is treated in the same manner as in the case of suppurative abscess, that is, with removal of some of the necrotic septa, irrigation with hydrogen pe­roxide, and leaving a tube in the wound cavity. The pos­toperative care of the patient is also the same as that in suppurative abscess, except that subcutaneous or intra­venous injections of an antigangrenous serum in physio­logical salt solution are given (10 to 12 prophylactic do­ses of the serum, primarily for B. perfingens, to 500 ml of physiological solution). It is advisable to make these injections under general anesthesia. Should signs oi iur-ther tissue crepitation appear after iirst dressings, addi­tional incisions must be made.

Operation for anorectal abscess with anaerobic lym­phangitis. This condition is characterized by the develop­ment of an anaerobic lymphangitis which originates from ischiorectal tissues and which spreads towards the scro­tum, femoral lymph nodes, and on to the anterior abdo­minal wall. The lesion spreads in foci where passive hyperemia and distinct crackling (tissue crepitation) may be elicited on palpation.

This is an emergency operation performed under ge­neral anesthesia. With the patient in the same position as that used for hemorrhoidectomy, the ischiorectal nec-rotic tissues are widely dissected. If there is crepitation in the groin or scrotal root area the overlying tissues are also widely dissected (Fig. 70,1).

The patient is then transferred to the supine position his legs are stretched, the entire abdominal wall is pain­ted with a 2 per cent iodine tincture, and wide trans-verst or oblique — transverst incisions are made over those areas of the abdominal wall where passive hyperemia and crepitation are elicited by palpation (Fig. 70,2). These incisions must be deep, with the abdominal muscles incised up to the transverse abdominal fascia. After hemostasis is instituted by means of catgut, a 4 per cent hydrogen peroxide solution is applied 2 or 3 times to the wounds and a thin rubber tube with side openings is laid deep inside each of the wounds (two tubes are laid into the largest wound). The wounds are then packed with gauze well soaked in hydrogen peroxide, and cove­red with a double-layer gauze impregnated with Vishnevsky ointment. A thick layer of cotton wool is now laid on the wounds, and the anterior abdominal wall is bandaged with a wide bandage. The outer ends of the rubber tubes should protrude from the dressing 3 to 5 cm (Fig. 70,3). Six or 70 ml of 4 per cent hydrogen peroxide are introduced into the wounds through these every 4 hours. Otherwise the postoperative care is similar to that in suppurative abscess. Dressings should be applied each day to see that hyperemia and crepitation do not spread any further. If they do, a new wide incision is necessary.

 The steps in the operation for suppurative abscesses

The steps in the operation for suppurative abscesses

The steps in the operation in anorectal abscess with anaerobic lymphangitis

Fig. 68 The steps in the operation for suppurative abscesses:

1. Wide incision of the perineum. (Occasionally it is made through necrotic tissues).

2. The abscess cavity is washed with hydrogen pero­xide.

3. Necrotic tissues are excised at the scrotal root.

4. Cotton-gauze dressing, with the drainage tubes brought out to the outside.

Fig. 69 Operation in gangrenous abscess. Radial sions of perineal and gluteal integuments.

Fig. 70 The steps in the operation in anorectal abscess with anaerobic lymphangitis:

1. Wide dissection of crepitating tissues in the gluteal and scrotal root areas

2. Transverse incisions of skin integument and apo-neurosis of the abdominal wall.

3. Appearance of the dressing applied to the abdomi­nal wall: rubber tubes are brought out to irrigate the wounds

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